Nokea
A danger following a bone marrow transplantation is graft-host disease. The initial sign of graft-versus-host disease is:
- A. Chest pain
- B. Rash
- C. EKG changes
- D. Fever
Correct Answer: B
Rationale: A rash is often the earliest sign of graft-versus-host disease, reflecting immune attack on the skin. Other signs may follow but are less initial.
You may also like to solve these questions
An adult is admitted with nausea, vomiting, and diarrhea. The client is receiving an IV of dextrose 5% in water with 40 mEq of KCl. The nurse knows the potassium is added to do which of the following?
- A. Replace potassium lost because of vomiting and diarrhea
- B. Replace potassium that the client is not getting from his diet
- C. Stop the nausea
- D. Stop the diarrhea
Correct Answer: A
Rationale: Vomiting and diarrhea cause significant potassium loss, requiring IV potassium replacement to prevent hypokalemia.
A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen?
- A. Inject into the upper arm where the sleeve can be pulled up
- B. Inject into the most accessible vein
- C. Inject through the clothing into thigh and hold in place for 10 seconds
- D. Take the child inside, remove excess clothing, and inject into the thigh
Correct Answer: C
Rationale: Injecting through clothing into the thigh (C) ensures rapid administration during anaphylaxis. Arm injection (A) is incorrect, IV injection (B) is not for EpiPens, and delaying to remove clothing (D) is dangerous.
A community health nurse is preparing to administer influenza vaccines. Which clients can safely receive the live-attenuated, intranasal influenza vaccine? Select all that apply.
- A. 4-month-old client who is receiving scheduled vaccinations
- B. 3-year-old client who is afraid of needles
- C. 24-year-old client who is 6 weeks postpartum
- D. 32-year-old client who is pregnant at 12 weeks gestation
- E. 45-year-old client with a history of HIV
Correct Answer: B, C
Rationale: The live-attenuated vaccine is safe for healthy individuals aged 2-49, like the 3-year-old (B) and postpartum client (C). It's contraindicated for infants under 2 (A), pregnant women (D), and immunocompromised clients (E).
The nurse is collecting data from a client during the first routine prenatal examination. According to the last menstrual period, the estimated gestational age is 12 weeks. The nurse would expect to palpate the uterine fundus
- A. 12 cm above the umbilicus
- B. at the level of the umbilicus
- C. just below the xiphoid process
- D. just above the symphysis pubis
Correct Answer: D
Rationale: At 12 weeks, the uterine fundus is just above the symphysis pubis (D). It reaches the umbilicus at 20 weeks and higher levels later in pregnancy.
The nurse is caring for a client with tuberculosis who is on airborne isolation precautions. The nurse can delegate which tasks to experienced unlicensed assistive personnel? Select all that apply.
- A. Alert the x-ray department about maintaining airborne isolation precautions
- B. Explain to the client why the client must wear a mask during transport to another department
- C. Post signs for airborne isolation precautions on the client's door and stock necessary equipment
- D. Remind visitors to wear a respirator mask and keep the door closed while in the client's room
- E. Talk with the family about the reasons for airborne isolation precautions in the client
Correct Answer: C, D
Rationale: Posting signs and stocking equipment (C) and reminding visitors about precautions (D) are within UAP scope. Alerting departments (A), explaining to the client (B), and educating family (E) require nursing judgment.